利多卡因胶浆在三腔二囊管压迫止血技术中的应用体会

目的 分析利多卡因胶浆应用于三腔二囊管压迫止血中的作用.方法 探讨总结12例应用利多卡因胶浆在三腔二囊管压迫术治疗肝硬化食管胃底静脉曲张破裂并出血的护理经验,主要做好三腔二囊管压迫术前的用物准备,术中的操作程序.结果 12例患者食管胃底静脉曲张破裂并出血均得到有效控制.结论 认为该方法的应用有利于食管胃底静脉曲张破裂并出血的迅速止血,降低死亡率提高患者的生存质量,延长寿命.     

食管胃底静脉曲张破裂出血三腔管压迫治疗的护理

食管胃底静脉曲张破裂出血是肝硬化失代偿期患者最严重的并发症之一。采用三腔管压迫止血,是一种有效控制出血的非手术治疗方法,近期止血率达90％,为进一步抢救治疗赢得了时间。本院实施三腔管压迫止血治疗52例,现将护理报告如下。     

食管胃底静脉曲张患者再次应用三腔双囊管压迫止血的护理

肝硬化门静脉高压引起食管胃底静脉曲张所致的上消化道大出血病势凶险,首次出血病死率高达50％.三腔双囊管压迫止血是治疗食管胃底静脉曲张破裂出血的首选方法.食管胃底静脉曲张所致的上消化道大出血6周内再出血发生率为17％,2年内再出血的发生率约80％[1].我科2006-2011年成功应用三腔双囊管压迫止血治疗上消化道大出血患者27例.6例因出血复发而需要再次使用三腔双囊管压迫止血,其中3例患者拒绝应用,现对其拒绝原因和护理对策分析如下.     

三腔二囊管治疗食管胃底静脉曲张破裂大出血28例

目的探讨三腔二囊管在治疗食管胃底静脉曲张破裂出血中的价值。方法回顾性分析我院急诊使用三腔二囊管抢救28例食管胃底静脉曲张破裂出血案例。结果全部患者在使用后均能及时止血,仅1例拔管后再出血。结论三腔二囊管在食管胃底静脉曲张破裂大出血抢救中效果佳。     

生长抑素治疗食管静脉曲张破裂出血129例疗效观察

食管静脉曲张破裂出血是消化内科常见急证，也是肝硬化．肝癌患者的主要死因。治疗关键是迅速有效地止血。2003年以前我院采用垂体后叶素加三腔两囊管压迫止血疗效不理想，一但放松气囊压力易发生再出血。急诊内镜下硬化剂治疗，视野不清，达不到理想治疗效果。外科急诊手术风险大，死亡率高。因此药物治疗仍是目前临床急诊治疗食管静脉曲张破裂出血的重要方法。目前我院采用生长抑素治疗食管静脉曲张破裂出血，获得满意疗效，现总结报告如下：     

使用三腔二囊管患者的心理护理体会

食管胃底静脉曲张绝大多数继发于各种原因引起的肝硬化门静脉高压病,一旦破裂出血,可引起严重的急性消化道大出血,往往危及生命,病死率达40%.三腔二囊管压迫是控制食管胃底静脉曲张破裂出血,抢救生命的一种治疗手段.心理护理指在护理全过程中,护士应用心理学的理论和技能通过各种方式和途径,积极地影响患者的心理状态,以达到理想的护理目的.我科通过对25例使用三腔二囊管压迫止血的患者实施心理护理,减轻了患者的负性情绪,提高了插管成功率,提高了食管胃底静脉曲张破裂出血患者的救治率,现报道如下.     

食管静脉曲张破裂大出血的急救体会

目的 观察三腔二囊管在治疗食管静脉曲张破裂大出血中的价值.方法 对2008年1月至2011年6月我院消化内科住院治疗的218例食管静脉曲张破裂大出血患者的临床资料进行整理和分析,根据患者及患者家属的意愿分为气囊压迫止血组和药物治疗组,气囊压迫止血组食管静脉曲张破裂大出血患者在使用奥曲肽进行治疗的基础上给予三腔二囊管压迫止血,药物治疗组仅进行奥曲肽治疗,观察24 h,比较两组治疗的临床疗效.结果 气囊压迫止血组91例患者有效,有效率为83.49%,而药物治疗组78例有效,有效率为71.56%,经χ2检验两组治疗有效率差异有统计学意义(χ2=4.449,P=0.035).结论 三腔二囊管联合奥曲肽疗效优于单纯药物治疗,是治疗食管静脉曲张破裂大出血安全有效的治疗方案,可进行临床推广运用.     

镇痛泵用于三腔二囊管治疗上消化道大出血的护理

目的:探讨镇痛泵用于三腔二囊管压迫治疗食管胃底静脉曲张破裂出血的效果及其护理措施。方法:对因食管胃底静脉曲张破裂消化道大出血使用三腔二囊管压迫止血的患者,以数字评定量表进行疼痛评估,对评估为中度以上疼痛者(疼痛评分4分)使用护士控制的镇痛泵,方法为枸橼酸芬太尼、氟比洛芬酯联合用药以微量注射泵持续小剂量泵入。观察镇痛效果及不良反应和并发症发生率。结果:18例患者中4例患者疼痛评分为4~6分(中度疼痛),14例患者疼痛评分为7~10分(重度疼痛),使用镇痛泵后疼痛明显缓解(无痛或仅有轻度疼痛,疼痛评分0~3分)。16例患者住监护室5~9d后病情稳定,转至普通病房;2例患者死亡。无1例患者发生呼吸抑制。结论:食管胃底静脉曲张破裂出血使用三腔二囊管压迫止血的患者有中重度的疼痛,使用护士控制的镇痛泵能达到满意的镇痛效果,且不增加不良反应和并发症的发生率。     

介绍一种改良式三腔二囊管拔管方法

传统的三腔二囊管压迫止血是治疗食管、胃底静脉曲张破裂出血的临床首选的应急止血措施之一，近期止血效果可达85%-92%。在整个止血过程中，三腔二囊管的拔管是最后也是最关键的一步，如操作不当引起拔管困难、拔管后再出血，将导致三腔二囊管压迫止血前功尽弃，对患者的身心造成极大的伤害。有研究表明其拔管后再出血发生率可达50%［1］。作者为寻求一种更为理想的拔管技术，提高拔管成功率，对传统拔管技术进行了改良，临床应用70例患者，收到了良好效果。现报告如下。     

三腔二囊管压迫止血的护理体会

食管胃底静脉曲张破裂出血是临床上的危急重症,临床特点是出血量大、速度迅猛,短时间内即可出现休克,且止血困难,并发症多。三腔二囊管压迫止血是针对食管胃底静脉曲张破裂引起大出血的重要抢救措施之一,自1950年推出以来一直为临床常用的止血法,止血率约为50％～80%。它不仅能压迫止血,还可通过胃管观察胃内止血情况并向胃内注入止血药物。     

内镜下套扎术联合奥曲肽治疗食管静脉曲张破裂出血的临床疗效

目的分析探讨内镜下套扎术联合奥曲肽治疗食管静脉曲张破裂出血的临床疗效。方法选取2005年10月～2012年5月在本院治疗的食管静脉曲张破裂出血患者82例,随机分为对照组和观察组,对照组患者采取内镜下套扎术治疗,观察组患者采取内镜下套扎术联合奥曲肽治疗,分别分析两组患者的疗效、并发症及治疗前后食管静脉曲张的程度。结果与对照组相比,观察组患者临床疗效明显增强,并发症明显减少,治疗后食管静脉曲张程度得到明显改善,差异有统计学意义（P〈0.05）。结论内镜下套扎术联合奥曲肽可有效提高临床效果,改善再出血率,减轻患者的痛苦,提高患者的生活质量和临床质量,值得推广。     

内镜套扎术联合药物治疗食管静脉曲张破裂出血36例

目的：探讨食管静脉曲张套扎术（EVL）结合药物综合治疗食管静脉曲张破裂出血的ll缶床效果。方法：消化科自1996年7月～2007年6月,收治肝硬化食管静脉曲张破裂出血病人36例,均采用EVL联合应用生长抑素及奥美拉唑治疗。结果：生长抑素及奥美拉唑联合内镜套扎治疗36例肝硬化并食道静脉曲张破裂出血患者,短期止血成功率达100％。结论：EVL联合应用生长抑素及奥美拉唑综合治疗,近期止血成功率高、再出血发生率低、并发症少。     

Current approaches to the management of patients with liver cirrhosis who have acute esophageal variceal bleeding

Objective:

Esophageal variceal bleeding is the most dangerous complication in patients with liver cirrhosis, and it is accompanied by high mortality. Their treatment can be complex, and requires a multidisciplinary approach. This review examines current approaches to the management of patients with liver cirrhosis who have acute esophageal variceal bleeding.

Methods:

PubMed, Google Scholar, and Cochrane Systematic Reviews were searched for articles published between 1987 and 2015. Relevant articles were identified using the following terms: ‘esophageal variceal bleeding’, ‘portal hypertension’ and ‘complications of liver cirrhosis’. The reference lists of articles identified were also searched for other relevant publications. Inclusion criteria were restricted to the management of patients with liver cirrhosis who have acute esophageal variceal bleeding.

Results:

It is currently recommended to combine vasoactive drugs (preferable somatostatin or terlipressin) and endoscopic therapies (endoscopic band ligation as first choice, sclerotherapy if endoscopic band ligation not feasible) for the initial treatment of acute variceal bleeding. Antibiotic prophylaxis must be regarded as an integral part of the treatment. The use of a Sengstaken–Blakemore tube is appropriate only in cases of refractory bleeding if the above methods cannot be used. An alternative to balloon tamponade may be the installation of self-expandable metal stents. The transjugular intrahepatic portosystemic shunt is an extremely useful technique for the treatment of acute bleeding from esophageal varices. Although most current clinical guidelines classify it as second-line therapy, the Baveno VI workshop recommends early transjugular intrahepatic portosystemic shunt with expanded polytetrafluoroethylene-covered stents within 72?h (ideally <24?h) in patients with esophageal variceal bleeding at high risk of treatment failure (e.g. Child–Turcotte–Pugh class C?<?14 points or Child–Turcotte–Pugh class B with active bleeding) after initial pharmacological and endoscopic therapy. Urgent surgical intervention is rarely performed and can be considered only in case of failure of conservative and/or endoscopic therapy and being unable to use a transjugular intrahepatic portosystemic shunt. Among surgical operations described in the literature are a variety of portocaval anastomosis and azygoportal disconnection procedures.

Conclusions:

To improve the results of treatment for patients with liver cirrhosis who develop acute esophageal variceal bleeding, it is important to stratify patients into risk groups, which will allow one to tailor therapeutic approaches to the expected results.     

肝硬化食管静脉曲张内镜下套扎27例临床疗效分析

目的探讨采用胃镜套扎止血治疗肝硬化食管静脉曲张破裂出血患者的疗效。方法对27例肝硬化患者进行常规的胃镜检查,确诊食管静脉曲张程度,随后在胃镜下对曲张静脉进行急诊、择期单次或多次套扎,其中7例食管静脉曲张破裂出血患者进行急诊胃镜检查并行胃镜下套扎术,20例进行择期胃镜下套扎术。结果27例肝硬化食管静脉曲张套扎术患者中25例（92.6%）在术后2~3周复查胃镜,静脉曲张程度均明显减轻,部分患者静脉曲张完全消失,急诊抢救及择期胃镜下套扎术止血成功率均在90%以上。结论胃镜下食管静脉曲张套扎术是治疗食管静脉曲张破裂出血及预防出血的有效措施。     

套扎及硬化术治疗食管下段胃底静脉曲张15例分析

目的探讨食管下段胃底静脉曲张内镜下治疗及其安全性.方法 1995年3月至2005年5月对15例食管下段胃底静脉曲张患者行硬化和套扎治疗. 结果 1例胃底静脉曲张出血急诊硬化治疗后血止,硬化术中出血4例,经再次注射或附加气囊压迫后血止,套扎术未并发术中出血,1例套扎术后第13天再次出血,内科治疗无效,改行手术治疗. 结论内镜治疗对食管下段胃底静脉曲张疗效较满意,初步印象中套扎治疗对静脉曲张明显者安全性较高.     

肝硬化食管静脉曲张内镜下套扎临床疗效分析

目的探讨肝硬化食管静脉曲张破裂出血患者在胃镜下行套扎术的临床疗效及安全性。方法回顾分析2010年1月～2012年12月42例胃镜下行套扎术的肝硬化食管静脉曲张破裂出血患者的临床资料。结果42例患者常规胃镜检查,确诊食管静脉曲张程度,其中30例进行择期胃镜下套扎术,12例食管静脉曲张破裂出血患者进行急诊胃镜检查并行胃镜下套扎术,急诊抢救及择期胃镜下套扎术止血成功率均在90％以上,38例患者在术后2～3周复查胃镜,静脉曲张程度均明显减轻。部分患者静脉曲张完全消失。结论单纯套扎治疗曲张静脉安全、有效,且创伤小、成功率高、并发症少。     

内镜下硬化治疗、套扎及硬化治疗加套扎治疗食管静脉曲张出血的对照研究

目的 探讨内镜下食管静脉曲张硬化治疗(EVS)、食管静脉曲张套扎(EVL)和EVL加序贯EVS 3种方法治疗静脉曲张的疗效,比较3组食管静脉曲张消失率、并发症和远期复发出血率.方法 79例乙型病毒性肝炎后肝硬化并食管静脉曲张,近期有食管静脉曲张破裂出血患者,年龄28～84岁,随机分为EVS组32例,EVL组22例,EVS EVL组25例.结果 并发症总发生率:EVS组43.8%,EVL组22.7%,EVS EVL组32.0%,EVS组高于其他2组,但3组差异无显著性(P＞0.05).治疗结束后,3组静脉曲张消失率分别为84.3%、81.3%、88.0%,差异无显著性(P＞0.05).随访1年、2年静脉曲张复发率:EVS组(12.5%、31.3%)和EVS EVL组(12.0%、34.3%)明显低于EVL组(36.4%、65.2%)(P＜0.05),EVS EVL组静脉曲张复发率与EVS组差异无显著性(P＞0.05).结论 联合治疗较单一EVL治疗食管静脉曲张远期复发率低,而EVL EVS在减少并发症和预防再发出血优于EVS治疗,是一个可取的方法.     

经内镜血管内硬化治疗食管静脉曲张分析

目的总结血管内注射硬化剂治疗食管静脉曲张的经验。方法对21例食管静脉曲张患者行内镜下血管内硬化注射治疗,其中16例为急诊硬化治疗。结果静脉曲张消失率85%,急诊止血率93.75%,并发近期再出血2例,占9.5%;食管穿孔1例,占4.76%;食管轻度狭窄1例,占4.76%。结论血管内硬化注射是治疗食管静脉曲张的一种安全、有效、相对较经济的治疗方法,并发症较少,急诊硬化治疗效果满意。     

Meta-analysis: endoscopic variceal ligation for primary prophylaxis of oesophageal variceal bleeding

BACKGROUND: The treatment effects of primary prophylactic endoscopic variceal ligation are unclear. AIM: To compare the treatment effects of endoscopic variceal ligation and beta-blockers for primary prophylaxis of oesophageal variceal bleeding. In addition, a subgroup analysis was done with the purpose to delineate differences in the effects of intervention that were biologically based. METHODS: We performed a literature search for randomized controlled trials, which compared the treatment effects of endoscopic variceal ligation with beta-blockers for primary prophylaxis of oesophageal variceal bleeding. Of the 955 articles screened, eight randomized-controlled trials including 596 subjects (285 with endoscopic variceal ligation and 311 with beta-blockers) were analysed. Outcomes measures evaluated were first gastrointestinal bleed, first variceal bleed, all-cause deaths, bleed-related deaths and severe adverse events. The measure of association employed was relative risk; with heterogeneity and sensitivity analyses. RESULTS: Variceal obliteration was obtained in 261 (91.6%) patients and target beta-blockers therapy was achieved in 294 (94.5%) patients (P = 0.19). Endoscopic variceal ligation compared with beta-blockers significantly reduced rates of first gastrointestinal bleed by 31% (RR, 0.69; 95% CI: 0.49-0.96; P = 0.03; NNTB = 15) and first variceal bleed by 43% (RR, 0.57; 95% CI: 0.38-0.85; P = 0.0067; NNTB = 11). All-cause deaths and bleed-related deaths were unaffected (RR, 1.03; 95% CI: 0.79-1.36; P = 0.81 and RR, 0.84; 95% CI: 0.44-1.61; P = 0.60 respectively). Severe adverse events were significantly less in endoscopic variceal ligation compared with beta-blockers (RR, 0.34; 95% CI: 0.17-0.69; P = 0.0024; NNTB = 28). Sensitivity analysis of five trials published in peer review journals and four trials with high quality showed results similar to those seen in the primary analysis of all the eight trials, confirming stability of conclusions. Following variceal obliteration with endoscopic variceal ligation, oesophageal varices recurred in 83 (29.1%) patients. Seven (28.1%) patients bled with one fatal outcome. In subgroup analyses, endoscopic variceal ligation had significant advantage compared wtih beta-blockers in trials including < or =30% patients with alcoholic cirrhosis, >30% patients with Child Class C cirrhosis and >50% patients with large varices. CONCLUSIONS : In patients with cirrhosis with moderate to large varices and who have not bled, endoscopic varices ligation compared with beta-blockers significantly reduced bleeding episodes and severe adverse events, but had no effect on mortality.     

Systematic review: endoscopic and imaging-based techniques in the assessment of portal haemodynamics and the risk of variceal bleeding

Background  Invasive measurement of the hepatic venous pressure gradient (HVPG) is regarded as the gold standard for risk stratification and the evaluation of pharmaceutical agents in patients with portal hypertension.
Aim  To review the techniques for endoscopic and imaging-based assessment of portal haemodynamics, with particular emphasis on trials where the results were compared with HVPG or direct portal pressure measurement.
Methods  Systematic search of the MEDLINE electronic database with keywords: portal hypertension, variceal bleeding, variceal pressure, endoscopic ultrasound, Doppler ultrasonography, magnetic resonance angiography, CT angiography, hepatic venous pressure gradient.
Results  Computed tomography angiography and endoscopic ultrasound (EUS) have been both employed for the diagnosis of complications of portal hypertension and for the evaluation of the efficacy of endoscopic therapy. Colour Doppler ultrasonography and magnetic resonance angiography has given discrepant results. Endoscopic variceal pressure measurements either alone or combined with simultaneous EUS, correlate well with HVPG and risk of variceal bleeding and have a low interobserver variability.
Conclusions  Endoscopic and imaging-based measurements of portal haemodynamics provide an alternate means for the assessment of complications of portal hypertension. Further studies are required to validate their use in risk stratification and the evaluation of drug therapies in patients with portal hypertension.